Abstract
Aim:
The purpose of the study was to comparatively evaluate temporomandibular joint function and treatment response using joint vibration analysis (JVA) in patients exhibiting disc displacement with reduction (DDR), treated with three variable thickness of stabilization splints. JVA analyzed these vibrations to detect internal joint abnormalities, and their patterns were further categorized using the Piper classification was highly accurate and hence used over magnetic resonance imaging.
Settings and Design:
Randomized clinical trial.
Materials and Methods:
The splint of different thicknesses, i.e., Group A (3 mm), Group B (4 mm), and Group C (5 mm) were given to the study participants for 10 week interval, and pre and posttreatment efficacy was recorded using JVA. Stress perseverance and tooth wear index were recorded with a pre and postquestionnaire.
Statistical Analysis Used:
The one way analysis of variance f test and Turkey’s post hoc test for multiple comparisons were used to statistically assess the results.
Results:
The treatment response with Group A and B thickness of stabilization splints was significant (P = 0.01) and with Group C was not significant (P = 5.28). The statistical result of stress perseverance was not significant between the three groups, although reflecting female participants were affected more. The tooth wear index was significant with all the three groups (P = 0.09).
Conclusion:
The study concluded that the splints given to Group A and Group B showed effective treatment response, while Group C showed positive response in a few individuals, but some individuals compliant of discomfort. The stress level was high in female individuals. Among all the participants, the concern of tooth wear was present.
Keywords: Disk displacement with reduction, joint vibration analysis, stabilization splints, temporomandibular joint disorders
INTRODUCTION
The temporomandibular joint (TMJ) is a complex articulation between the temporal bone and the mandibular condyle, crucial for the movements of the jaw. The TMJ allows for both rotation and translation, enabling a wider range of jaw motion.[1] Temporomandibular disorders (TMDs) are common conditions characterized by abnormalities in the joint, most notably internal derangements such as disc displacements, which may occur even in asymptomatic individuals.[2] These disorders represent a multifactorial group of conditions influenced by genetic, hormonal, and environmental factors, with peak incidence between ages 20 and 40, and a higher prevalence in women. TMD is often associated with systemic manifestations and mental well-being issues, often the anxiety and depression, which can further impact patients’ overall health.[3] The condition is the leading cause of the pain in the orofacial region, significantly affecting quality of life (QoL).[4] Factors contributing to TMD include emotional tension, tooth loss, occlusal issues, muscular dysfunction, and changes in the TMJ itself.[5]
Joint vibration analysis (JVA) was developed by John Radke of Bioresearch Associates in 1990 as a diagnostic tool for TMJ disorders.[6] JVA uses accelerometers to measure vibrations produced by the TMJ components (the disc and condyle) during jaw movements. These vibrations are analyzed to detect internal joint abnormalities, providing information about disc displacement.[7] It also measures the amplitude and waveform pattern of the vibrations, which are associated with the severity and stage of internal TMJ dysfunction. These patterns can be categorized using the Piper classification, helping to track disease progression. JVA has demonstrated a high diagnostic accuracy with 98% specificity (correctly identifying cases where no disease exists) and 70%–95% sensitivity (correctly identifying disease when present), depending on the specific TMJ condition.[8] Although magnetic resonance imaging (MRI) is often considered the “gold standard” for assessing TMJ disorders and pathology, its use is minimal due to expenses, complexity of procedure, and accessibility. JVA, in contrast, offers a more accessible and cost-effective diagnostic option.[9]
The use of splints, particularly stabilization splints, is a common and effective approach in the treatment of TMDs. Stabilization splints are designed to compensate for abnormal occlusal forces, helping to redistribute the forces toward the teeth and TMJ.[10] These splints can lead to changes in bite forces over time, which may alleviate symptoms of TMDs, including pain, discomfort, and dysfunction. The preferred thickness for stabilization splints typically ranges from 3 to 5 mm, although a wider range from 3 to 15 mm has been reported in clinical practice.[11]
While various types of splints have been compared in terms of their effectiveness in treating TMDs, the specific impact of different splint thicknesses on treatment outcomes has not been investigated. Furthermore, the efficacy of using the JVA as a diagnostic tool also needed to be determined. Therefore, the goal of this study was to assess the effectiveness of different thickness of stabilization splints in treating TMD using JVA as a novel diagnostic tool.
MATERIALS AND METHODS
The study was carried out in the Department of Prosthodontics and was registered in the Clinical Trial of India (REF/2020/07/035096). After IEC approval, with informed consent of the patients, willing to be a part of the trial, the study was conducted in patients belonging to the age group of 18–55 years.[12] The inclusion criteria were patients having disc displacement with reduction (DDR), clicking/pain in TMJ region present, reduced and/or deviated mouth opening, and any other symptoms using research diagnostic criteria (RDC)-TMD criteria.[12] The exclusion criteria were asymptomatic patients, patients with disc displacement without reduction, medically compromised patients, and patients not willing to take part in the study. To reduce the impact of variable factors on the observations and the final results, every effort was taken to standardize the methods throughout the investigation. The JVA recorder device as shown in Figure 1 was used to record the joint vibration on the left and right TMJ.
Figure 1.
Joint vibration analysis device
Sample size and technique
A total of 30 patients were included in the study, i.e., n = 10 in each group according to the parent article using the formula:-
Where, S is the standard deviation (SD), Z1 and Z2 are the desired level of significance, and M1 and M2 are the mean of two groups. With the α =0.05 and β =0.2, with the power of 80% (i.e., actual power = 0.8169). Input: Effect size f = 0.56; α err prob = 0.05; Power (1−β err prob) =0.8; for Number of groups = 3; Total sample size = 30 was achieved. The abovementioned formula was used to calculate the sample size of two groups, and the third group sample size was considered similar to the first two groups. The software used was Epi Info statistical software version 7 by CDC (Centers for Disease Control and Prevention) in Atlanta, Georgia (US). Thus, with an effect size of 0.56 and a significance threshold of 0.05, a minimum projected sample size of 30 samples, which was further divided as 10 samples per group; a total of 3 groups would provide 80% power to detect significant changes. The Shapiro–Wilks test was used to test for normality of the data. The probability value (P value) threshold used for rejecting the null hypothesis was 0.001. In the present study, one-way Analysis of Variance (ANOVA) f-test was applied to find out the mean difference. Tukey’s HSD post hoc Test was applied to make pairwise multiple comparisons to find out the difference between each pair of mean values of the three groups included in the study.
The participants were randomly allocated by a lottery system (Computerized distribution) into three different groups, wherein three different splint thickness was used. *(To ensure randomization and reduce bias) Consort guidelines[13] were followed during the study. The samples were divided into 3 groups as follows: Group A: Splint thickness of 3 mm; Group B: Splint thickness of 4 mm; Group C: Splint thickness of 5 mm. Proper counseling of the subjects was done to avoid dropouts, and a mild painkiller was prescribed in case of any pain or discomfort.
The workflow involved the following steps:
Diagnostic evaluation of a patient
Patient written informed consent was taken after the complete procedure was explained to the patient
Random allocation with lottery system (computerized distribution) of the patient into the 3 different intervention group
Questionnaire-based data collection recorded
Baseline JVA was recorded as given in Figure 2
Splint fabrication and wear instructions given to the patient as shown in Figure 3
Patient follow-up was at 3rd, 5th, and 7th week interval after which post questionnaire based data were collected[14,15,16]
Postoperative JVA was performed after completion of 10 weeks as shown in Figure 4.
Figure 2.
Pretreatment joint vibration analysis record
Figure 3.
Fabrication of stabilization splint. (a) face bow orientation, (b) centric and protrusive bite record, (c) fabrication of splint on articulator, (d) intraoral splint
Figure 4.
Post treatment joint vibration analysis record
JVA of test patients was carried out to analyse seven integral subgroup parameters of three main experimental groups as recorded in Table 1. The pair wise mean value of different subgroups, i.e., a)total integral value pre and total integral post, b) max opening pre and max opening post, c) integral <300 pre and integral <300 post, d) integral >300, pre and integral > 300 post, e) ratio pre and ratio post, f)peak frequency pre and peak frequency post, g) peak amplitude pre and peak amplitude post, which are the parameter in the JVA of all the three different interventions group, i.e., 3 mm, 4 mm, and 5 mm thicknesses of stabilized splint were obtained and given in Graph 1a-g.
Table 1.
Master chart of JVA analysis
| Name | Gender | Side | Total integral pre | Total integral post | Maximum opening pre | Maximum opening post | Integral <300 pre | Integral <300 post | Integral >300 pre | Integral >300 post | Ratio pre | Ratio post |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre- and post-joint vibration analysis record for patients treated with 3 mm stabilization splint | ||||||||||||
| Patient 1 | Female | Left | 93.6 | 13.5 | 40 | 40 | 76.5 | 10.8 | 17.2 | 27.2 | 0.22 | 0.25 |
| Right | 68 | 40 | 40 | 40 | 52.3 | 35.8 | 15.7 | 4.1 | 0.3 | 0.12 | ||
| Patient 1 | Female | Left | 66 | 14.8 | 44 | 40 | 52.5 | 13.7 | 26.5 | 1.1 | 0.51 | 0.08 |
| Right | 120 | 52.4 | 44 | 40 | 95.1 | 41.1 | 24.4 | 11.3 | 0.26 | 0.28 | ||
| Patient 3 | Male | Left | 8.1 | 20.5 | 44 | 50 | 7.5 | 18.9 | 0.6 | 1.6 | 0.09 | 0.08 |
| Right | 24.5 | 9.8 | 44 | 50 | 23.5 | 9 | 1 | 0.8 | 0.04 | 0.09 | ||
| Patient 4 | Female | Left | 17.5 | 18 | 44 | 58 | 17 | 16.1 | 0.5 | 1.9 | 0.03 | 0.12 |
| Right | 6.7 | 20.2 | 44 | 58 | 6.1 | 17.2 | 0.7 | 3 | 0.11 | 0.18 | ||
| Patient 5 | Female | Left | 117 | 12.8 | 40 | 44 | 21.2 | 11.8 | 0.11 | 0.9 | 1.5 | 0.08 |
| Right | 20 | 9.2 | 40 | 44 | 18.5 | 8.6 | 0.08 | 0.6 | 1.7 | 0.07 | ||
| Patient 6 | Male | Left | 15.3 | 11.1 | 44 | 55 | 14.7 | 10.2 | 0.6 | 0.8 | 0.04 | 0.08 |
| Right | 32.8 | 20 | 44 | 55 | 31.6 | 18.7 | 1.2 | 1.3 | 0.04 | 0.07 | ||
| Patient 7 | Female | Left | 7.7 | 25.7 | 50 | 46 | 7.3 | 18.4 | 0.4 | 7.3 | 0.05 | 0.39 |
| Right | 38.4 | 16.4 | 50 | 46 | 37.6 | 12.3 | 0.8 | 4.1 | 0.02 | 0.34 | ||
| Patient 8 | Female | Left | 27.3 | 9.1 | 45 | 50 | 26.5 | 8.5 | 0.8 | 0.5 | 0.03 | 0.06 |
| Right | 11.1 | 23.5 | 45 | 50 | 10.2 | 22.7 | 1 | 0.7 | 0.09 | 0.03 | ||
| Patient 9 | Female | Left | 12.5 | 17.2 | 40 | 40 | 12 | 16.5 | 0.5 | 0.7 | 0.04 | 0.04 |
| Right | 2.8 | 6.5 | 40 | 40 | 2.5 | 6.1 | 0.4 | 0.4 | 0.15 | 0.07 | ||
| Patient 10 | Female | Left | 14.5 | 12.2 | 42 | 42 | 14 | 10.5 | 0.6 | 0.4 | 0.08 | 0.04 |
| Right | 4.8 | 8.5 | 42 | 42 | 6.5 | 12.5 | 0.5 | 0.4 | 0.10 | 0.07 | ||
| Pre- and post-joint vibration analysis record for patients treated with 4 mm stabilization splint | ||||||||||||
| Patient 1 | Male | Left | 21 | 16.2 | 47 | 48 | 20.3 | 15.3 | 0.6 | 0.8 | 0.03 | 0.06 |
| Right | 72 | 15.3 | 47 | 48 | 14.4 | 14.1 | 0.7 | 1.2 | 0.05 | 0.08 | ||
| Patient 2 | Male | Left | 13.5 | 13.3 | 48 | 48 | 12.5 | 12 | 1 | 1.3 | 0.08 | 0.11 |
| Right | 5.6 | 7.1 | 48 | 48 | 5 | 6.1 | 0.7 | 1 | 0.14 | 0.17 | ||
| Patient 3 | Female | Left | 27.3 | 9.1 | 45 | 50 | 26.5 | 8.5 | 0.8 | 0.5 | 0.03 | 0.06 |
| Right | 11.1 | 23.5 | 45 | 50 | 10.2 | 22.7 | 1 | 0.7 | 0.09 | 0.03 | ||
| Patient 4 | Female | Left | 13.2 | 10 | 43 | 39 | 12.5 | 9.4 | 0.7 | 0.7 | 0.06 | 0.07 |
| Right | 5.5 | 45.5 | 43 | 39 | 5 | 44.1 | 0.5 | 1.4 | 0.11 | 0.03 | ||
| Patient 5 | Female | Left | 87.2 | 32.2 | 46 | 44 | 84.8 | 30.6 | 2.5 | 1.5 | 0.03 | 0.05 |
| Right | 71 | 25.6 | 46 | 44 | 53.6 | 24.1 | 8.2 | 1.5 | 0.15 | 0.06 | ||
| Patient 6 | Female | Left | 36.5 | 15.3 | 52 | 46 | 34.6 | 14.1 | 1.9 | 1.2 | 0.06 | 0.09 |
| Right | 19.3 | 14.1 | 52 | 46 | 18.8 | 12.8 | 0.5 | 1.3 | 0.03 | 0.1 | ||
| Patient 7 | Male | Left | 9.3 | 11.6 | 44 | 46 | 8.8 | 11.2 | 0.5 | 0.4 | 0.06 | 0.04 |
| Right | 4.4 | 6.8 | 44 | 46 | 3.8 | 6.4 | 0.6 | 0.4 | 0.16 | 0.07 | ||
| Patient 8 | Female | Left | 69 | 31.8 | 34 | 46 | 46.9 | 30.3 | 9.4 | 1.5 | 0.2 | 0.05 |
| Right | 81.8 | 26.6 | 34 | 46 | 54.6 | 23.6 | 27.1 | 3.1 | 0.5 | 0.13 | ||
| Patient 9 | Female | Left | 31.5 | 24.3 | 43 | 43 | 30.4 | 26.4 | 1.1 | 1.2 | 0.04 | 0.03 |
| Right | 6.4 | 5.3 | 43 | 43 | 6.1 | 4.9 | 0.4 | 0.8 | 0.06 | 0.06 | ||
| Patient 10 | Male | Left | 28.5 | 24.3 | 42 | 43 | 28.4 | 26.4 | 0.9 | 1.2 | 0.03 | 0.03 |
| Right | 4.4 | 5.3 | 42 | 43 | 4.1 | 4.9 | 0.2 | 0.8 | 0.04 | 0.06 | ||
| Pre- and post-joint vibration analysis record for patients treated with 5 mm stabilization splint | ||||||||||||
| Patient 1 | Male | Left | 12.6 | 21.2 | 58 | 58 | 11.7 | 19.1 | 0.9 | 2 | 0.07 | 0.11 |
| Right | 8.2 | 15.1 | 58 | 58 | 7.6 | 13.1 | 0.6 | 2 | 0.08 | 0.15 | ||
| Patient 2 | Female | Left | 70.5 | 8.8 | 47 | 36 | 69.9 | 8.1 | 0.6 | 0.7 | 0.01 | 0.09 |
| Right | 49 | 11.7 | 47 | 36 | 33.8 | 10.8 | 0.5 | 0.9 | 0.01 | 0.09 | ||
| Patient 3 | Male | Left | 55.2 | 8.7 | 50 | 56 | 53 | 6.7 | 2.2 | 2 | 0.04 | 0.3 |
| Right | 6.5 | 53.5 | 50 | 56 | 5.6 | 41.6 | 0.9 | 11.8 | 0.16 | 0.28 | ||
| Patient 4 | Female | Left | 18 | 2.7 | 49 | 41 | 10.3 | 2.4 | 0.8 | 0.4 | 0.07 | 0.16 |
| Right | 60.1 | 3.9 | 49 | 41 | 58.8 | 3.5 | 1.3 | 0.4 | 0.02 | 0.11 | ||
| Patient 5 | Male | Left | 33.8 | 35.7 | 57 | 57 | 32.9 | 28.9 | 0.9 | 73.8 | 0.03 | 0.26 |
| Right | 50 | 27.8 | 57 | 57 | 16.1 | 24.1 | 0.9 | 27.7 | 0.06 | 0.11 | ||
| Patient 6 | Female | Left | 38.3 | 15.7 | 49 | 42 | 24.5 | 14.1 | 13.7 | 1.6 | 0.56 | 0.11 |
| Right | 6.8 | 13.7 | 49 | 42 | 5.5 | 12.6 | 1.2 | 1.1 | 0.22 | 0.09 | ||
| Patient 7 | Female | Left | 22.7 | 48.3 | 45 | 48 | 19.2 | 47 | 3.5 | 1.4 | 0.18 | 0.03 |
| Right | 112 | 35.6 | 45 | 48 | 22.4 | 34.8 | 2.9 | 0.8 | 0.13 | 0.02 | ||
| Patient 8 | Female | Left | 14.5 | 14.5 | 46 | 34 | 13.8 | 14.2 | 0.7 | 0.4 | 0.05 | 0.03 |
| Right | 29.1 | 17.5 | 46 | 34 | 28.3 | 17 | 0.8 | 0.5 | 0.03 | 0.03 | ||
| Patient 9 | Female | Left | 20 | 9.7 | 47 | 46 | 12.3 | 8.7 | 1.2 | 1.4 | 0.05 | 0.06 |
| Right | 62.1 | 55.5 | 47 | 46 | 60.8 | 45.6 | 1.6 | 13.8 | 0.07 | 0.29 | ||
| Patient 10 | Male | Left | 36.8 | 4.7 | 55 | 40 | 34.9 | 1.4 | 0.7 | 0.6 | 0.06 | 0.18 |
| Right | 52 | 3.9 | 55 | 40 | 18.1 | 2.5 | 0.9 | 0.6 | 0.09 | 0.21 | ||
Graph 1.
Descriptive means plot of the three different groups of stabilization splint. (a) Mean of total integral of three groups, (b) Mean of maximum mouth opening of three, (c) Integral and amplitude < 300 Hz of three groups, (d) Integral and amplitude > 300 Hz of three group, (e) Ratio of integral and amplitude of three group, (f) Peak frequency of three group, (g) Peak amplitude of three group
Statistical analysis was done with Epi Info statistical software vs. 7 by CDC (Centers for Disease Control and Prevention) in Atlanta, Georgia (US). Parametric tests were employed for analysis because the data were normally distributed and of the continuous type. We computed the mean and SD. The One-way ANOVA test and Tukey’s post hoc test were the statistical tests used for the data collected for this investigation.
RESULTS
ANOVA f-test was used to calculate the pair-wise mean of different subgroups, and it showed that a significant difference was present across all three groups with P = 0.001 (P < 0.05), showing significant change post-treatment in all groups. To test the hypothesis, a pairwise comparison of mean strength was carried out using Tukey’s HSD test was given in Table 2 as indicated. To ascertain which groups contributed to overall significance; using Tukey’s post hoc test was given in Table 3, Table 4 presents a pairwise comparison of each group. It shows statistically significant difference (P = 0.01) exists in comparison of change with the different thickness of stabilization splint on the TMJ in the interventional treatment period of 10 weeks between Group A (Splint of 3 mm thickness) and Group B (Splint of 4 mm thickness) (i.e., P < 0.05). Statistically significant difference (P > 0.05) exists between Group B (Splint of 4 mm thickness) and Group C (Splint of 5 mm thickness) as (P = 0.528), showing no significant relation between the groups. The statistically significant difference (P < 0.05) was found between Group A (Splint of 3 mm thickness) and Group C (Splint of 5 mm thickness) i.e., (P = 0.01). During the study interval questionnaire of TMJ evaluation was collected, giving the level of significance to be P = 0.21 i.e., (P > 0.05), concluding that there was no definite statistical difference between the three groups with the aspect TMJ evaluation of given in Table 4.
Table 2.
Individual pair-wise comparison between the three groups was performed using Tukey’s post hoc test
| Tukey’s post hoc test to find individual pairwise comparison | |||
|---|---|---|---|
| Group | Comparison group | Mean difference | P (significance) |
| Group A (splint of 3 mm thickness) | Group B (splint of 4 mm thickness) | 5.8 | 0.011* |
| Group C (splint of 5 mm thickness) | 1.6 | 5.28* | |
| Group B (splint of 4 mm thickness) | Group C (splint of 5 mm thickness) | 5.9 | 0.01* |
*p >0.05 – not significant
Table 3.
Individual pairwise comparison between the three groups was performed using Tukey’s post hoc test
| Tukey’s post hoc test to find individual pairwise comparison | |||
|---|---|---|---|
| Group | Comparison group | Mean difference | P (significance) |
| Group A (splint of 3 mm thickness) | Group B (splint of 4 mm thickness) | 5.8 | 0.011* |
| Group C (splint of 5 mm thickness) | 1.6 | 5.28* | |
| Group B (splint of 4 mm thickness) | Group C (splint of 5 mm thickness) | 5.9 | 0.01* |
*p >0.05 – not significant
Table 4.
Comparison between three groups for the temporomandibular joint evaluation
| Source of variation | SS | Df | MS | F | P |
|---|---|---|---|---|---|
| Between groups | 4.44 | 8 | 0.55 | 1.7 | 0.21 |
| Within groups | 2.5 | 8 | 0.31 | ||
| Total | 6.94 | 16 |
SS: Sum of square, Df: Degree of freedom, MS: Mean square
Further, the pre- and post-stress perseverance responses[16] were recorded as shown in Table 5. The comparison of values between Group A, Group B, and Group C is graphically represented in Graph 2. The statistical difference between all three groups was not significant as (P > 0.05), i.e., (P = 0.2).
Table 5.
Pre and post stress perseverance record of splint of different thickness
| Name | Gender | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Pre- and post-stress perseverance record of splint thickness of 5 mm | |||||||||||||||||||||
| Patient 1 | Female | 4 | 2 | 3 | 4 | 4 | 3 | 3 | 0 | 2 | 3 | 3 | 0 | 3 | 2 | 2 | 0 | 3 | 3 | 2 | 2 |
| Patient 2 | Female | 3 | 3 | 2 | 2 | 2 | 2 | 4 | 4 | 3 | 3 | 1 | 1 | 3 | 2 | 3 | 2 | 3 | 2 | 2 | 2 |
| Patient 3 | Male | 0 | 0 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 2 | 2 | 1 | 1 | 2 | 2 | 3 | 3 | 3 | 3 |
| Patient 4 | Female | 3 | 3 | 3 | 2 | 3 | 2 | 4 | 3 | 3 | 3 | 2 | 2 | 4 | 3 | 2 | 2 | 2 | 2 | 2 | 2 |
| Patient 5 | Female | 4 | 3 | 4 | 3 | 4 | 3 | 2 | 4 | 2 | 2 | 3 | 2 | 0 | 3 | 1 | 1 | 4 | 2 | 3 | 2 |
| Patient 6 | Male | 2 | 2 | 3 | 3 | 2 | 2 | 3 | 3 | 2 | 2 | 2 | 2 | 2 | 2 | 3 | 3 | 2 | 2 | 2 | 2 |
| Patient 7 | Female | 3 | 2 | 4 | 2 | 4 | 2 | 4 | 4 | 4 | 3 | 3 | 2 | 3 | 4 | 4 | 2 | 3 | 2 | 3 | 2 |
| Patient 8 | Female | 4 | 3 | 4 | 3 | 4 | 3 | 0 | 1 | 0 | 0 | 4 | 3 | 0 | 1 | 0 | 1 | 4 | 3 | 4 | 4 |
| Patient 9 | Female | 3 | 3 | 3 | 3 | 3 | 3 | 3 | 2 | 2 | 2 | 2 | 3 | 2 | 3 | 2 | 4 | 3 | 3 | 3 | 3 |
| Patient 10 | Female | 3 | 2 | 3 | 4 | 3 | 3 | 2 | 0 | 2 | 3 | 2 | 0 | 3 | 2 | 3 | 0 | 2 | 3 | 2 | 2 |
| Pre- and post-stress perseverance record of splint thickness of 4 mm | |||||||||||||||||||||
| Patient 1 | Male | 2 | 2 | 1 | 3 | 2 | 2 | 4 | 2 | 4 | 3 | 1 | 1 | 4 | 3 | 1 | 2 | 1 | 2 | 1 | 1 |
| Patient 2 | Male | 3 | 3 | 2 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 3 | 3 | 1 | 1 |
| Patient 3 | Female | 4 | 3 | 4 | 3 | 4 | 3 | 0 | 3 | 0 | 0 | 4 | 3 | 0 | 1 | 0 | 1 | 4 | 3 | 4 | 4 |
| Patient 4 | Female | 1 | 2 | 2 | 1 | 2 | 2 | 4 | 2 | 3 | 2 | 2 | 2 | 3 | 3 | 2 | 2 | 0 | 1 | 0 | 0 |
| Patient 5 | Female | 2 | 2 | 2 | 2 | 2 | 1 | 2 | 1 | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 2 | 2 | 2 |
| Patient 6 | Female | 1 | 1 | 1 | 1 | 2 | 1 | 3 | 1 | 3 | 3 | 1 | 1 | 3 | 3 | 2 | 2 | 2 | 1 | 1 | 1 |
| Patient 7 | Male | 1 | 2 | 3 | 3 | 1 | 2 | 2 | 2 | 3 | 2 | 3 | 1 | 3 | 3 | 3 | 1 | 3 | 3 | 3 | 3 |
| Patient 8 | Female | 3 | 3 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 4 | 2 | 3 | 2 | 2 | 2 | 1 | 1 | 2 | 2 |
| Patient 9 | Female | 3 | 3 | 1 | 1 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 3 | 2 | 1 | 1 |
| Patient 10 | Male | 3 | 2 | 2 | 4 | 2 | 3 | 2 | 3 | 2 | 3 | 2 | 0 | 3 | 2 | 2 | 0 | 3 | 3 | 1 | 1 |
| Pre- and-post stress perseverance record of splint thickness of 5 mm | |||||||||||||||||||||
| Patient 1 | Male | 3 | 2 | 3 | 4 | 3 | 3 | 2 | 0 | 2 | 3 | 2 | 0 | 2 | 2 | 1 | 0 | 2 | 3 | 2 | 2 |
| Patient 2 | Female | 3 | 3 | 3 | 3 | 4 | 3 | 3 | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 3 | 1 | 3 | 2 | 2 | 2 |
| Patient 3 | Male | 3 | 3 | 3 | 4 | 4 | 4 | 3 | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 3 | 2 | 3 | 4 | 2 | 3 |
| Patient 4 | Female | 2 | 2 | 2 | 2 | 3 | 3 | 3 | 2 | 3 | 2 | 1 | 3 | 1 | 2 | 2 | 2 | 2 | 2 | 3 | 2 |
| Patient 5 | Male | 3 | 2 | 2 | 2 | 3 | 2 | 3 | 3 | 2 | 3 | 3 | 2 | 2 | 1 | 3 | 2 | 3 | 2 | 2 | 2 |
| Patient 6 | Female | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 3 | 2 | 3 | 2 | 2 | 2 | 3 |
| Patient 7 | Female | 2 | 2 | 2 | 3 | 3 | 3 | 3 | 1 | 2 | 3 | 2 | 2 | 2 | 3 | 3 | 2 | 2 | 2 | 2 | 3 |
| Patient 8 | Female | 2 | 2 | 3 | 2 | 3 | 2 | 1 | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 3 | 2 | 3 | 2 |
| Patient 9 | Female | 2 | 2 | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 3 | 2 | 2 | 2 | 1 | 2 | 2 | 2 | 2 | 2 | 2 |
| Patient 10 | Male | 2 | 2 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 3 | 2 | 2 | 2 | 3 | 2 | 3 | 2 | 2 | 2 | 3 |
Graph 2.
Mean difference between Group A, Group B and Group C with the total count of male and female affected in the study
Dental status was observed and noted with Tooth Wear Index Using Smith and Knight Criteria[17] as shown in Table 6. Tooth wear was compared between Group A, Group B, Group C with mean of 1.0 for Group A, 1.1 for Group B, 1.0 for Group C, along with level of significance (P = 0.9) among the three group and distribution of score among three group is graphically represented in Graph 3 of three Group A, Group B, and Group C statistical difference of 0.092 between the groups was observed.
Table 6.
Pre- and post-tooth wear index record with splint thickness of 3 mm, 4 mm, 5 mm
| Patient number | Pretooth wear index with 3 mm splint |
Posttooth wear index with 3 mm splint | Pretooth wear index with 4 mm splint | Posttooth wear index with 4 mm splint | Pretooth wear index with 5 mm splint | Posttooth wear index with 5 mm splint |
|---|---|---|---|---|---|---|
| Patient 1 | 1 | 1 | 1 | 1 | 1 | 1 |
| Patient 2 | 0 | 0 | 1 | 2 | 2 | 2 |
| Patient 3 | 0 | 1 | 1 | 1 | 0 | 0 |
| Patient 4 | 1 | 2 | 0 | 0 | 1 | 1 |
| Patient 5 | 1 | 1 | 1 | 1 | 1 | 1 |
| Patient 6 | 1 | 1 | 1 | 1 | 2 | 2 |
| Patient 7 | 1 | 1 | 1 | 2 | 2 | 2 |
| Patient 8 | 0 | 0 | 0 | 1 | 1 | 1 |
| Patient 9 | 1 | 2 | 0 | 0 | 0 | 0 |
| Patient 10 | 1 | 1 | 1 | 1 | 0 | 0 |
Graph 3.
Representation of the tooth wear index score of different groups
DISCUSSION
Clinically, intracapsular TMJ disorders can be identified by the presence of a “click” and limited mouth opening. Disruptions in the condyle-disc complex may occur, sometimes resulting in either a reduction in mouth opening or a complete lockjaw, ascribed to the superior retrodiscal lamina’s decreased flexibility. According to Okeson, the typical range of mouth opening is generally between 25 and 30 mm, with a tendency for deflection towards the affected side during opening. It has been suggested that less invasive treatments, which support joint adaptive relocation through the use of stabilization splints and anterior repositioning splints, are advisable. Consequently, in the present study, the stabilization splint was preferred over the anterior repositioning splint as it can lead to posterior open bite. A stabilization splint for the maxillary arch can be worn for 24 h and can be altered in the centric position to maintain neuromuscular harmony.[18] Dylina stated that neuromuscular harmony in the masticatory system is established that creates a mechanical disadvantage for parafunctional forces. These splints lower superior tissue pressures by opening the vertical dimension and somewhat decompressing the condylar head when not in use.[9] Occlusal splint can reduce the facial pain by reducing the proprioceptive and sensory feedback is been noticed. These splints either permissive or nonpermissive splint have following function (a). Allow the condyle to sit in CR, (b) the get muscles relaxed, (c) to lower cellular hypoxia levels; (d) to prevent bruxism of teeth and related structures; (e) to lessen the proprioception of the periodontal ligament; and (f) to offer diagnostic information. The masticatory muscular pain is reduced by incorporation of stabilization splint according to Türp et al., but long-term efficacy and effectiveness are not evident due to the lack of randomized control trial giving definitive results.[19] Kostrzewa-Janicka et al. in stated that a splint with less thickness is not necessarily helpful to decrease bite force, it is mainly the vertical jaw separation that settles the joint to most relaxed position, decreasing bite fore and reduce pain in the muscle.[20] The highest bite force is applied with thin splint. A similar kind of statement was stated in a study by Hamata et al. that the stabilized splint fabricated at centric relation and maximum intercuspation shows a reduction of TMD symptoms, which is not permanent, as this reduces electromyographic activity posttherapy.[21] The study conducted by Ekberg et al. concluded that short-term efficacy of stabilization appliances for a duration of 10 weeks shows definitive outcomes and effect on TMD pain, supporting the conducted study time interval.[22] A notable decrease in the amplitude of the condyle was noticed, giving the level of significance to be P = 0.21. In our study the splint with 3 mm thickness has shown better results (P < 0.05), which is in accordance with a study by Tang et al. in, which stated that the splint of different thickness reduces the amplitude of vibration caused in TMJ and gets mild with decreased thickness of splint.[23]
The emotional stress is a major etiology of most TMDs, with the condition being more common in females with less bilateral joint involvement and clicking and pain in the affected site.[16] Along with this, TMD patients self-report higher degrees of anxiety, despair, and somatization. Because of these physiological characteristics, the body’s tolerance to pain and stress was lowered.[16] In the study also participants have also experienced a greater number of stress events in the past 6 months. Women reflected a higher prevalence of estrogen activity. In the study by Lajnert et al., in[24] that used RDC/TMD protocol for diagnosis recommend introduction of psychological therapy for the chronic painful conditions with was also met our inclusion criteria for diagnosis. A review by Berger et al. in showed personality traits such as neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness mentioning that the patient with TMD have mostly associated with low self-esteem, habit of onychophagia, malasia, and chastrophizing.[25] The stress evaluation that was performed during the study gave a sufficient score with the reduction in the stress level post treatment but was independent of the thickness of the splint as statistical difference between the three groups was which was not significant as (P > 0.05). All the above factors associate with one’s QOL.
Bruxism was one of the major findings in the individuals with TMD but was not associated to the cause of attrition and facets on tooth as mentioned by Seligman et al. in was noticed in study conducted with Smith and Knight’s indexed score which was observed to be significant.[26] Similarly Pergamalian et al. in put forth the point of tooth wear factors did not differentiate with bruxism, and bruxism had no association with severe muscle pain but was associated with less pain with palpation in the TMJ.[27]
With evolution, clinical diagnosis is also supported with definite findings with the electronic jaw movement tracking devices such as JVA, Electromyography, and MRI. Which can be helpful in improving the condition of derangement or relaxation of tendered musculature with help of electric stimulation, which aids in the management of the disorder. In the study by Kondrat, et al., it has been stated that joint vibration helps indicating early signs of degeneration recorded through JVA which works on the principle of medial and peak amplitude parameters indicating the condition of subluxation of joint or ligament, referring to the Piper’s Classification.[28] It works irrespective of gender bias and evident results for early or latent dysfunction of joint is reported beneficial to design the intervention to be given.[29] With JVA as a tool a study was carried out by Devi et al. in (2017) comparing three different types of splint anterior repositioning splint, soft splint and centric stabilization splint with using total integral value of JVA parameter concluded centric stabilizing splint to give effective result and JVA increases accuracy of the diagnosis of DDR.[3] Huang, et al. in conducted a study on asymptomatic individuals and on patients with ADDWR, which positively showed higher frequency spectrogram in pathological TMJ conditions.[30]
Clinical implication
Within the limitations of this study, it becomes evident that JVA provided a considerably accurate diagnosis to detect early pathology of TMJ. This can be frequently brought into use and can be effectively used in asymptomatic populations and provide them with treatment intervention as early as possible to prevent further progression of the pathology. The stabilization splints of 3 mm, 4 mm and 5 mm can be effectively used as noninvasive, cost-effective treatment modality to restrict further progression of DDR into more severe pathology.
CONCLUSION
From this study conducted under standardized diagnostic criteria and an interventional program, the following conclusions can be drawn. All the three thickness of stabilization splint, i.e., 3 mm and 4 mm thickness of stabilization splint was comparatively effective. However, stabilization splints of 5 mm thickness were comfortable to some individual but mostly reflected sign of discomfort and difficulty in adaptation as compared to the two different groups. It is mostly suggested to start with the baseline treatment modality as the disorder is diagnosed.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
REFERENCES
- 1.Herb K, Cho S, Stiles MA. Temporomandibular joint pain and dysfunction. Curr Pain Headache Rep. 2006;10:408–14. doi: 10.1007/s11916-006-0070-7. [DOI] [PubMed] [Google Scholar]
- 2.de Leeuw R. Internal derangements of the temporomandibular joint. Oral Maxillofac Surg Clin North Am. 2008;20:159–68. doi: 10.1016/j.coms.2007.12.004. v. [DOI] [PubMed] [Google Scholar]
- 3.Devi J, Verma M, Gupta R. Assessment of treatment response to splint therapy and evaluation of TMJ function using joint vibration analysis in patients exhibiting TMJ disc displacement with reduction: A clinical study. Indian J Dent Res. 2017;28:33–43. doi: 10.4103/ijdr.IJDR_154_16. [DOI] [PubMed] [Google Scholar]
- 4.Miettinen O, Lahti S, Sipilä K. Psychosocial aspects of temporomandibular disorders and oral health-related quality-of-life. Acta Odontol Scand. 2012;70:331–6. doi: 10.3109/00016357.2011.654241. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Gauer RL, Semidey MJ. Diagnosis and treatment of temporomandibular disorders. Am Fam Physician. 2015;91:378–86. [PubMed] [Google Scholar]
- 6.Radke JC, Kull RS. Distribution of temporomandibular joint vibration transfer to the opposite side. Cranio. 2012;30:194–200. doi: 10.1179/crn.2012.030. [DOI] [PubMed] [Google Scholar]
- 7.Piper M. Piper’s Classification of TMJ Disorders. 2013. Available from: http://www.tmjsurgery.com/ . [Last retrieved on 2013 Jun 01]
- 8.Ribeiro-Rotta RF, Marques KD, Pacheco MJ, Leles CR. Do computed tomography and magnetic resonance imaging add to temporomandibular joint disorder treatment? A systematic review of diagnostic efficacy. J Oral Rehabil. 2011;38:120–35. doi: 10.1111/j.1365-2842.2010.02133.x. [DOI] [PubMed] [Google Scholar]
- 9.Dylina TJ. A common-sense approach to splint therapy. J Prosthet Dent. 2001;86:539–45. doi: 10.1067/mpr.2001.118878. [DOI] [PubMed] [Google Scholar]
- 10.Schmitter M, Zahran M, Duc JM, Henschel V, Rammelsberg P. Conservative therapy in patients with anterior disc displacement without reduction using 2 common splints: A randomized clinical trial. J Oral Maxillofac Surg. 2005;63:1295–303. doi: 10.1016/j.joms.2005.05.294. [DOI] [PubMed] [Google Scholar]
- 11.Durrani S, Bhandari R, Lalithadevi P, Munireddy S, Priya P. Joint vibration analysis of temporomandibular joint in asymptomatic patients in the age group between 18-25 years: An in-vivo study. Int J Oral Care Res. 2015;3:30–8. [Google Scholar]
- 12.Schiffman E, Ohrbach R, Truelove E, Look J, Anderson G, Goulet JP, et al. Diagnostic criteria for temporomandibular disorders (DC/TMD) for clinical and research applications: Recommendations of the International RDC/TMD Consortium Network and Orofacial Pain Special Interest Group. J Oral Facial Pain Headache. 2014;28:6–27. doi: 10.11607/jop.1151. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Garrocho-Rangel A, Ruiz-Rodríguez S, Gaitán-Fonseca C, Pozos-Guillén A. Randomized clinical trials in pediatric dentistry: Application of evidence-based dentistry through the CONSORT statement. J Clin Pediatr Dent. 2019;43:219–30. doi: 10.17796/1053-4625-43.4.1. [DOI] [PubMed] [Google Scholar]
- 14.Pettengill CA, Growney MR, Jr., Schoff R, Kenworthy CR. A pilot study comparing the efficacy of hard and soft stabilizing appliances in treating patients with temporomandibular disorders. J Prosthet Dent. 1998;79:165–8. doi: 10.1016/s0022-3913(98)70211-2. [DOI] [PubMed] [Google Scholar]
- 15.Tjakkes GH, Reinders JJ, Tenvergert EM, Stegenga B. TMD pain: The effect on health related quality of life and the influence of pain duration. Health Qual Life Outcomes. 2010;8:46. doi: 10.1186/1477-7525-8-46. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Matovu M, Zubairi AM. Self-perceived assessment competencies and practices among university lecturers. J Appl Res High Educ. 2014;6:269–84. [Google Scholar]
- 17.López-Frías FJ, Castellanos-Cosano L, Martín-González J, Llamas-Carreras JM, Segura-Egea JJ. Clinical measurement of tooth wear: Tooth wear indices. J Clin Exp Dent. 2012;4:e48–53. doi: 10.4317/jced.50592. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Okeson JP. Joint intracapsular disorders: Diagnostic and nonsurgical management considerations. Dent Clin North Am. 2007;51:85–103. doi: 10.1016/j.cden.2006.09.009. vi. [DOI] [PubMed] [Google Scholar]
- 19.Türp JC, Komine F, Hugger A. Efficacy of stabilization splints for the management of patients with masticatory muscle pain: A qualitative systematic review. Clin Oral Investig. 2004;8:179–95. doi: 10.1007/s00784-004-0265-4. [DOI] [PubMed] [Google Scholar]
- 20.Kostrzewa-Janicka J, Mierzwińska-Nastalska E, Jarzębski G, Okoński P. Vertical jaw separation for vertical thickness of occlusal stabilization splint. Int J Stomatol Occlusion Med. 2012;5:20–7. [Google Scholar]
- 21.Hamata MM, Zuim PR, Garcia AR. Comparative evaluation of the efficacy of occlusal splints fabricated in centric relation or maximum intercuspation in temporomandibular disorders patients. J Appl Oral Sci. 2009;17:32–8. doi: 10.1590/S1678-77572009000100007. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Ekberg EC, Vallon D, Nilner M. Occlusal appliance therapy in patients with temporomandibular disorders. A double-blind controlled study in a short-term perspective. Acta Odontol Scand. 1998;56:122–8. doi: 10.1080/00016359850136102. [DOI] [PubMed] [Google Scholar]
- 23.Tang Y, Li H, Chen Y, Zhu L, Kang H. Effect of different splint thicknesses on occlusal function and temporomandibular joint sounds: Clinical report. Open J Stomatol. 2018;8:326. [Google Scholar]
- 24.Lajnert V, Francisković T, Grzic R, Kovacević Pavicić D, Bakarbić D, Buković D, et al. Depression, somatization and anxiety in female patients with temporomandibular disorders (TMD) Coll Antropol. 2010;34:1415–9. [PubMed] [Google Scholar]
- 25.Berger M, Oleszek-Listopad J, Marczak M, Szymanska J. Psychological aspects of temporomandibular disorders-literature review. Curr Issues Pharm Med Sci. 2015;28:55–9. [Google Scholar]
- 26.Seligman DA, Pullinger AG, Solberg WK. The prevalence of dental attrition and its association with factors of age, gender, occlusion, and TMJ symptomatology. J Dent Res. 1988;67:1323–33. doi: 10.1177/00220345880670101601. [DOI] [PubMed] [Google Scholar]
- 27.Pergamalian A, Rudy TE, Zaki HS, Greco CM. The association between wear facets, bruxism, and severity of facial pain in patients with temporomandibular disorders. J Prosthet Dent. 2003;90:194–200. doi: 10.1016/s0022-3913(03)00332-9. [DOI] [PubMed] [Google Scholar]
- 28.Kondrat W, Sierpińska T, Radke J. Assessment of the temporomandibular joint function in young adults without complaints from the masticatory system. Int J Med Sci. 2018;15:161–9. doi: 10.7150/ijms.21665. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Akbulut N, Altan A, Akbulut S, Atakan C. Evaluation of the 3 mm thickness splint therapy on temporomandibular joint disorders (TMDs) Pain Res Manag. 2018;2018:3756587. doi: 10.1155/2018/3756587. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Huang ZS, Lin XF, Li XL. Characteristics of temporomandibular joint vibrations in anterior disk displacement with reduction in adults. Cranio. 2011;29:276–83. doi: 10.1179/crn.2011.041. [DOI] [PubMed] [Google Scholar]